The Heart in Systemic Autoimmune Diseases

Handbook of Systemic Autoimmune Diseases

The Heart in Systemic Autoimmune Diseases

Volume Fourteen

Second Edition

Editors

Fabiola Atzeni

Rheumatology Unit, L. Sacco University Hospital, Milan, Italy

Andrea Doria

Department of Medicine and Rheumatology Unit, University of Padova Medical School, Padova, Italy

Michael Nurmohamed

Amsterdam Rheumatology and immunology Center, Departments of Rheumatology Reade & VU University Medical Center Amsterdam, The Netherlands

Paolo Pauletto

University of Padova Medical School, Department of Internal Medicine Treviso, Italy

Table of Contents

Cover image

Title page

Handbook of Systemic Autoimmune Diseases

Copyright

Dedication

List of Contributors

Preface

Chapter 1. Cellular Immunity: A Role for Cytokines

1. Introduction

2. Autoimmunity in Myocarditis

3. Pathogenesis: The Role of Cells and Cytokines

Chapter 2. Organ-Specific Autoimmunity Involvement in Cardiovascular Disease

1. Introduction

2. Post-Myocardial Infarction (Dressler) Syndrome

3. Post-Pericardiotomy Syndrome and Idiopathic Recurrent Acute Pericarditis

4. Rheumatic Carditis

5. Dilated Cardiomyopathy and Myocarditis

6. Idiopathic Tachy and Bradyarrhythmias

7. Systemic Arterial Hypertension

Chapter 3. Neonatal Lupus Syndromes: Pathogenesis and Clinical Features

1. Introduction

2. Epidemiology and Definition of Congenital Complete AVB

3. Etiology/Pathogenesis

4. Risk of Delivering a Child With Complete CHB

5. Clinical Manifestations

6. Treatment

7. Obstetric Management of Pregnancies at Risk of Developing CCHB

8. Prognosis

9. Other Pregnancy Outcomes in Women With Anti-Ro/SSA Antibodies

10. Anti-Ro/SSA Negative CHB

Chapter 4. Subclinical Cardiovascular Damage in Systemic Rheumatic Diseases

1. Introduction

2. Epidemiology and Role of Traditional Risk Factors

3. Subclinical Atherosclerosis

4. Cardiovascular Effects of Pharmacological Treatments

Chapter 5. Atherosclerosis and Autoimmunity

1. Introduction

2. Prevalence and Epidemiology

3. Pathogenesis

4. Clinical Manifestations

5. Diagnostic Investigations

6. Treatment

Chapter 6. Inflammasomes and Inflammatory Cytokines in Early Atherosclerosis

1. Introduction

2. Lipid Dysregulation in Autoimmunity

3. Innate Immunity and Inflammatory Signaling Mechanisms

4. Inflammasomes and IL-1β in Atherogenesis

5. β2-Glycoprotein I in Atherogenic Innate Immunity

6. Summary and Conclusions

Chapter 7. Treatment of Lipid Metabolism Disturbances in Autoimmune Diseases

1. Introduction

2. Lipid Metabolism Disturbances Relevant for Atherosclerosis and Cardiovascular Risk in Autoimmune Diseases

3. Serum Lipid Level Control in Autoimmune Diseases

4. Lipoprotein Function Modulation in Autoimmune Diseases

Chapter 8. Cardiac Imaging Techniques in Systemic Autoimmune Diseases

1. Introduction

2. Transthoracic Echocardiography

3. Transesophageal Echocardiography

4. Stress Echocardiography

5. Tissue Doppler Imaging

6. Speckle Tracking Echocardiography

7. Myocardial Contrast Echocardiography

8. Usefulness of Biomarkers of Endothelial Dysfunction

9. Carotid Ultrasonography

10. Conclusion

Chapter 9. New Cardiac Imaging Tools and Invasive Techniques in Systemic Autoimmune Diseases (Part II)

1. Introduction

2. Cardiac Magnetic Resonance Imaging

3. Computed Tomography

4. Right Heart Catheterization

5. Endomyocardial Biopsy

6. Conclusion

Chapter 10. Cardiac Diseases in Rheumatoid Arthritis

1. Introduction

2. Atherosclerotic Cardiovascular Disease in Rheumatoid Arthritis

3. Nonatherosclerotic Cardiovascular Disease

4. Conclusion

Chapter 11. Cardiac Involvement in Systemic Lupus Erythematosus

1. Introduction

2. Pericardial Involvement

3. Myocardial Involvement

4. Valvular Involvement

5. Coronary Artery Involvement

6. Conduction Tissue Involvement

7. Conclusions

Chapter 12. Cardiac Involvement in the Antiphospholipid Syndrome

1. Introduction

2. Epidemiology

3. Pathophysiology

4. Clinical Manifestations

5. Diagnostic Procedures

6. Differential Diagnosis

7. Treatment

8. Final Remarks

Chapter 13. Cardiac Involvement in Scleroderma

1. Introduction

2. Evidence for and Prognostic Impact of Clinical Cardiac Involvement

3. Prevalence of Subclinical Cardiac Involvement

4. Ischemic Heart Disease

5. Myocarditis

6. Hypertension

7. Arrhythmias

8. The Future

Chapter 14. Cardiac Involvement in Systemic Vasculitis

1. Introduction

2. Pathogenesis of Vasculitides

3. Cardiovascular Clinical Manifestations in Vasculitides

4. Evolution and Prognostic Factors

5. Treatment

6. Conclusions

Chapter 15. Cardiovascular Involvement in Ankylosing Spondylitis

1. Introduction

2. Cardiovascular Mortality in Ankylosing Spondylitis

3. Vascular Morbidity in Ankylosing Spondylitis

4. Cardiovascular Risk Factors in Ankylosing Spondylitis

5. Aortic Disease in Ankylosing Spondylitis

6. Mitral Valve Involvement in Ankylosing Spondylitis

7. Conduction Abnormalities in Ankylosing Spondylitis

8. Myocardium and Pericardium in Ankylosing Spondylitis

9. Subclinical Vascular Involvement in Ankylosing Spondylitis

10. Treatment and Its Implications in Atherosclerosis in Ankylosing Spondylitis

11. Conclusions

Chapter 16. Cardiovascular Involvement in Psoriatic Arthritis

1. Introduction

2. Epidemiology

3. Etiology/Pathogenesis

4. Clinical Manifestations

5. Diagnostic Investigations

6. Treatment

Chapter 17. Cardiovascular Involvement in Primary Sjögren's Syndrome

1. Introduction

2. Raynaud Phenomenon

3. Cardiovascular Disease

4. Autonomic Cardiovascular Features

5. Pulmonary Arterial Hypertension

6. Arrhythmias

7. Pericarditis

8. Myocarditis

Chapter 18. Gout and Heart Disease: A Two-Way Street?

1. Introduction

2. Gout—Overview

3. Cardiovascular Disease

4. Gout and Traditional Cardiovascular Risk Factors

5. Etiology and Pathogenesis

6. Diagnostic Interventions

7. Treatment

8. Future Perspectives

9. Conclusion

Chapter 19. Heart Involvement in Osteoarthritis

1. Introduction

2. Prerequisites: Pathophysiology of Osteoarthritis

3. Epidemiologic Data: Osteoarthritis and Cardiovascular Diseases, Two Endemic Diseases

4. Association Between Osteoarthritis and Cardiovascular Diseases: Shared Risk Factors

5. Association Between Osteoarthritis and Cardiovascular Diseases: Direct Link Beyond CV Risk Factors

6. Association Between Osteoarthritis and Cardiovascular Diseases: an Epiphenomenon?

7. New Perspectives: The Role of Microbiota

8. Conclusions

Chapter 20. Cardiac Effects of Antirheumatic Drugs

1. Introduction

2. Atherosclerosis and Metabolic Syndrome

3. Other Heart Diseases

4. Recommendations for Cardiovascular Risk Management in Arthritides

5. Conclusions

Index

Handbook of Systemic Autoimmune Diseases

Series Editor: F. Atzeni and P. Sarzi-Puttini

Volume 1  The Heart in Systemic Autoimmune Diseases

Edited by: Andrea Doria and Paolo Pauletto

Volume 2  Pulmonary Involvement in Systemic Autoimmune Diseases

Edited by: Athol U. Wells and Christopher P. Denton

Volume 3  Neurologic Involvement in Systemic Autoimmune Diseases

Edited by: Doruk Erkan and Steven R. Levine

Volume 4  Reproductive and Hormonal Aspects of Systemic Autoimmune Diseases

Edited by: Michael Lockshin and Ware Branch

Volume 5  The Skin in Systemic Autoimmune Diseases

Edited by: Piercarlo Sarzi-Puttini, Andrea Doria, Giampiero Girolomoni and Annegret Kuhn

Volume 6  Pediatrics in Systemic Autoimmune Diseases

Edited by: Rolando Cimaz and Thomas Lehman

Volume 7  The Kidney in Systemic Autoimmune Diseases

Edited by: Justin C. Mason and Charles D. Pusey

Volume 8  Digestive Involvement in Systemic Autoimmune Diseases

Edited by: Josep Font, Manuel Ramos-Casals and Juan Rodés

Volume 9  Endocrine Manifestations of Systemic Autoimmune Diseases

Edited by: Sara E. Walker and Luis J. Jara

Volume 10  Antiphospholipid Syndrome in Systemic Autoimmune Diseases

Edited by: Ricard Cervera, Joan Carles Reverter and Munther Khamashta

Volume 11  Pediatrics in Systemic Autoimmune Diseases, Second Edition

Edited by: Rolando Cimaz and Thomas Lehman

Volume 12  Antiphospholipid Syndrome in Systemic Autoimmune Diseases, Second Edition

Edited by: Ricard Cervera, Gerard Espinosa and Munther Khamashta

Volume 13  The Digestive Involvement in Systemic Autoimmune Diseases, Second Edition

Edited by: Manuel Ramos-Casals, Munther Khamashta, Pilar Brito-Zerón, Fabiola Atzeni and Joan Rodés Teixidor

Volume 14  The Heart in Systemic Autoimmune Diseases, Second Edition

Edited by: Fabiola Atzeni, Andrea Doria, Michael Nurmohamed and Paolo Pauletto

Copyright

Elsevier

Radarweg 29, PO Box 211, 1000 AE Amsterdam, Netherlands

The Boulevard, Langford Lane, Kidlington, Oxford OX5 1GB, United Kingdom

50 Hampshire Street, 5th Floor, Cambridge, MA 02139, United States

Copyright © 2017 Elsevier B.V. All rights reserved.

No part of this publication may be reproduced or transmitted in any form or by any means, electronic or mechanical, including photocopying, recording, or any information storage and retrieval system, without permission in writing from the publisher. Details on how to seek permission, further information about the Publisher’s permissions policies and our arrangements with organizations such as the Copyright Clearance Center and the Copyright Licensing Agency, can be found at our website: www.elsevier.com/permissions.

This book and the individual contributions contained in it are protected under copyright by the Publisher (other than as may be noted herein).

Notices

Knowledge and best practice in this field are constantly changing. As new research and experience broaden our understanding, changes in research methods, professional practices, or medical treatment may become necessary.

Practitioners and researchers must always rely on their own experience and knowledge in evaluating and using any information, methods, compounds, or experiments described herein. In using such information or methods they should be mindful of their own safety and the safety of others, including parties for whom they have a professional responsibility.

To the fullest extent of the law, neither the Publisher nor the authors, contributors, or editors, assume any liability for any injury and/or damage to persons or property as a matter of products liability, negligence or otherwise, or from any use or operation of any methods, products, instructions, or ideas contained in the material herein.

Library of Congress Cataloging-in-Publication Data

A catalog record for this book is available from the Library of Congress

British Library Cataloguing-in-Publication Data

A catalogue record for this book is available from the British Library

ISBN: 978-0-12-803997-7

ISSN: 1571-5078

For information on all Elsevier publications visit our website at https://www.elsevier.com/books-and-journals

Publisher: Sara Tenney

Acquisition Editor: Linda Versteeg-Buschmann

Editorial Project Manager: Halima Williams

Production Project Manager: Edward Taylor

Designer: Victoria Pearson

Typeset by TNQ Books and Journals

Dedication

Fabiola would like to thank her family and all of her friends for their incredible support and help during one of the most difficult periods of her life.

We would also like to thank Linda Versteeg-Buschman, Halima Williams, and their staff at Elsevier for their hard work. It has been a great pleasure to work with them on this second edition.

The Editors

List of Contributors

M. Afanasyeva,     Johns Hopkins Medical Institutions, Baltimore, MD, United States

R. Agca,     Amsterdam Rheumatology and Immunology Center and Reade, Amsterdam, The Netherlands

F. Atzeni

IRCCS Galeazzi Orthopedic Institute, Milan, Italy

Rheumatology Unit, L. Sacco University Hospital, Milan, Italy

N.U. Azmi,     Collaborative Research Center for Okayama Medical Innovation Center (OMIC) and Department of Cell Chemistry, Okayama University Graduate School of Medicine, Dentistry, and Pharmaceutical Sciences, Okayama, Japan

P. Brito-Zerón

Hospital CIMA-Sanitas, Barcelona, Spain

Laboratory of Autoimmune Diseases Josep Font, CELLEX-IDIBAPS, Department of Autoimmune Diseases, ICMiD, Hospital Clínic, Barcelona, Spain

A. Brucato,     Internal Medicine, Ospedale Papa Giovanni XXIII, Bergamo, Italy

J.P. Buyon,     Hospital for Joint Diseases, New York University School of Medicine, New York, NY, United States

A.L.P. Caforio,     Division of Cardiology, Department of Cardiological Thoracic and Vascular Sciences, Centro ‘V. Gallucci’, University of Padova-Policlinico, Padova, Italy

F. Caso,     Rheumatology Unit, Department of Clinical Medicine and Surgery, University Federico II, Naples, Italy

R. Cervera,     Department of Autoimmune Diseases, Hospital Clínic, Barcelona, Spain

R. Clancy,     Hospital for Joint Diseases, New York University School of Medicine, New York, NY, United States

J.G. Coghlan,     Royal Free Hospital, London, United Kingdom

M. Corda,     Cardiology Unit, Brotzu Hospital, Cagliari, Italy

A. Courties

Department of Rheumatology, DHU i2B, Saint-Antoine hospital, Assistance Publique–Hôpitaux de Paris (AP-HP), Paris, France

Sorbonnes Universités UPMC, Paris, France

C.P. Denton,     Royal Free and University College Medical School, London, United Kingdom

A. Doria,     University of Padova Medical School, Padova, Italy

G. Espinosa,     Department of Autoimmune Diseases, Hospital Clínic, Barcelona, Spain

D. Lisa Fairweather,     Johns Hopkins Medical Institutions, Baltimore, MD, United States

C. Ferri,     Rheumatology Unit, Azienda Policlinico of Modena, Department of Medical and Surgical Sciences, University of Modena and Reggio Emilia, Modena, Italy

M. Gatto,     Division of Rheumatology, University of Padova, Padova, Italy

M. Gerritsen,     Amsterdam Rheumatology and Immunology Center and Reade, Amsterdam, The Netherlands

L. Gianturco,     Cardiology Unit, IRCCS Galeazzi Orthopedic Institute, Milan, Italy

N. Haroon

Division of Rheumatology, University Health Network, Toronto, ON, Canada

University of Toronto, Toronto, ON, Canada

Krembil Research Institute, Toronto, ON, Canada

M. Heslinga,     Amsterdam Rheumatology and Immunology Center and Reade, Amsterdam, The Netherlands

L. Iaccarino,     Division of Rheumatology, University of Padova, Padova, Italy

S. Iliceto,     Division of Cardiology, Department of Cardiological Thoracic and Vascular Sciences, Centro ‘V. Gallucci’, University of Padova-Policlinico, Padova, Italy

L.R. Lopez,     Corgenix/Orgentec, Broomfield, CO, United States

G. Malipiero,     Hematology and Clinical Immunology, University of Padova, Padova, Italy

A. Manfredi,     Rheumatology Unit, Azienda Policlinico of Modena, Department of Medical and Surgical Sciences, University of Modena and Reggio Emilia, Modena, Italy

R. Marcolongo,     Hematology and Clinical Immunology, University of Padova, Padova, Italy

I.F. Masala,     Santissima Trinità Hospital, Cagliari, Italy

E. Matsuura,     Collaborative Research Center for Okayama Medical Innovation Center (OMIC) and Department of Cell Chemistry, Okayama University Graduate School of Medicine, Dentistry, and Pharmaceutical Sciences, Okayama, Japan

M. Meroni,     Internal Medicine, Ospedale Papa Giovanni XXIII, Bergamo, Italy

P.L. Meroni

University of Milan, Milan, Italy

IRCCS Istituto Auxologico Italiano, ASST G. Pini, Milan, Italy

C. Nardin,     Department of Medicine – DIMED, University of Padova Medical School and Medicina Interna 1, University Hospital Cà Foncello, Treviso, Italy

M. Nurmohamed,     Amsterdam Rheumatology and Immunology Center and Reade, Amsterdam, The Netherlands

P. Pauletto,     Department of Medicine – DIMED, University of Padova Medical School and Medicina Interna 1, University Hospital Cà Foncello, Treviso, Italy

R. Pérez-Álvarez,     Department of Internal Medicine, Hospital Alvaro Cunqueiro, Vigo, Spain

M. Pérez-de-Lis,     Department of Internal Medicine, Hospital Alvaro Cunqueiro, Vigo, Spain

C. Perricone,     Rheumatology, Department of Internal Medicine and Medical Speciality, University of la Sapienza Rome, Rome, Italy

M. Porcu,     Cardiology Unit, Brotzu Hospital, Cagliari, Italy

M. Ramos-Casals,     Sjögren Syndrome Research Group (AGAUR), Laboratory of Autoimmune Diseases Josep Font, CELLEX-IDIBAPS, Department of Autoimmune Diseases, ICMiD, University of Barcelona, Hospital Clínic, Barcelona, Spain

M. Rattazzi,     Department of Medicine – DIMED, University of Padova Medical School and Medicina Interna 1, University Hospital Cà Foncello, Treviso, Italy

I. Rodriguez-Pintó,     Department of Autoimmune Diseases, Hospital Clínic, Barcelona, Spain

N. Ronda,     Department of Pharmacy, University of Parma, Parma, Italy

N.R. Rose,     Department of Molecular Microbiology and Immunology, Johns Hopkins Medical Institutions, Baltimore, MD, United States

I. Sánchez Berná,     Department of Internal Medicine, Hospital Virgen de las Nieves, Granada, Spain

I. Sari

Division of Rheumatology, University Health Network, Toronto, ON, Canada

Division of Rheumatology, Department of Internal Medicine, Dokuz Eylul University, Izmir, Turkey

University of Toronto, Toronto, ON, Canada

P. Sarzi-Puttini,     Rheumatology Unit, L. Sacco University Hospital, Milan, Italy

M. Sebastiani,     Rheumatology Unit, Azienda Policlinico of Modena, Department of Medical and Surgical Sciences, University of Modena and Reggio Emilia, Modena, Italy

J. Sellam

Department of Rheumatology, DHU i2B, Saint-Antoine hospital, Assistance Publique–Hôpitaux de Paris (AP-HP), Paris, France

Sorbonnes Universités UPMC, Paris, France

L.H. Shen,     Collaborative Research Center for Okayama Medical Innovation Center (OMIC) and Department of Cell Chemistry, Okayama University Graduate School of Medicine, Dentistry, and Pharmaceutical Sciences, Okayama, Japan

Y. Shoenfeld,     Zabludowicz Center for Autoimmune Diseases, Sheba Medical Center, (Affiliated to Tel-Aviv University), Tel-Hashomer, Israel

A. Sisó-Almirall

Consorci d'Atenció Primària de Salut Barcelona Esquerre (CAPS-BE). Transversal Group for Research in Primary Care. Institut d'Investigacions Biomèdiques August Pi i Sunyer, (IDIBAPS) Barcelona, Spain

University of Barcelona, Barcelona, Spain

F.R. Spinelli,     Rheumatology, Department of Internal Medicine and Medical Speciality, University of la Sapienza Rome, Rome, Italy

Z. Szekanecz,     Department of Rheumatology, Faculty of Medicine, University of Debrecen, Debrecen, Hungary

X.W. Tan,     Collaborative Research Center for Okayama Medical Innovation Center (OMIC) and Department of Cell Chemistry, Okayama University Graduate School of Medicine, Dentistry, and Pharmaceutical Sciences, Okayama, Japan

M. Turiel,     Cardiology Unit, IRCCS Galeazzi Orthopedic Institute, Milan, Italy

M. Zen,     Division of Rheumatology, University of Padova, Padova, Italy

Preface

This second edition of The Heart in Systemic Autoimmune Diseases details the current state-of-the-art of cardiovascular disorders in patients with systemic and organ-specific autoimmune diseases.

The first chapters deal with general aspects, i.e., the role of immunity and autoimmunity in the etiology and pathogenesis of cardiac manifestations as well as the use of cardiovascular imaging in defining cardiovascular features.

The following chapters focus on clinical aspects, including identification, diagnosis, and treatment of cardiovascular involvement in organ-specific and rheumatic autoimmune diseases, spondyloarthropathies, vasculitis, and gout.

The last chapter reviews the cardiovascular complications associated with antirheumatic drugs, synthetics, and biologics used in everyday clinical practice.

We hope that you will find this book interesting and useful.

The Editors

Chapter 1

Cellular Immunity

A Role for Cytokines

D. Lisa Fairweather∗, M. Afanasyeva∗ and N.R. Rose§     ∗Johns Hopkins Medical Institutions, Baltimore, MD, United States     §Department of Molecular Microbiology and Immunology, Johns Hopkins Medical Institutions, Baltimore, MD, United States

Abstract

The heart is a remarkably durable and efficient pump that provides all cells of the body with nutrients and removes waste products. Myocarditis is a process characterized by an inflammatory infiltrate of the myocardium with necrosis and/or degeneration of adjacent myocytes not typical of the ischemic damage associated with coronary artery disease. Autoimmune heart disease following viral infection involves the production of key cytokines by immune cells such as macrophages and natural killer cells. Finally, if environmental or genetic factors allow overproduction of proinflammatory cytokines, then progression to chronic autoimmune myocarditis may follow. Importantly, myocarditis often precedes the development of dilated cardiomyopathy, which can lead to heart failure and the need for cardiac transplantation.

Keywords

Autoimmunity; Inflammation; Myocarditis; Myocytes; Natural killer

The chapter has been revised and updated by Francesco Caso, Rossella Talotta, and Fabiola Atzeni for the 2016 edition.

Key Points

• Myocarditis is a process characterized by an inflammatory infiltrate of the myocardium with necrosis and/or degeneration of adjacent myocytes not typical of the ischemic damage associated with coronary artery disease.

• The development of autoimmune heart disease following viral infection involves the production of key cytokines by immune cells such as macrophages and natural killer cells.

• Environmental or genetic factors allow overproduction of proinflammatory cytokines, then progression to chronic autoimmune myocarditis may follow.

1. Introduction

The heart is a remarkably durable and efficient pump that provides all cells of the body with nutrients and removes waste products. If cardiac dysfunction occurs for any reason, it can have devastating results. Consequently, heart disease accounts for the majority of illness and death in Western populations (Schoen, 1999). Myocarditis or inflammation of the heart muscle is a significant contributor to heart disease, especially in infants, children, and young adults, and its treatment remains problematic (Drory et al., 1991; Rose and Afanasyeva, 2003). Importantly, myocarditis often precedes the development of dilated cardiomyopathy (DC), which can lead to heart failure and the need for cardiac transplantation.

Myocardial inflammation is a major diagnostic characteristic of myocarditis. According to the current histologic definition based on the Dallas criteria, myocarditis is a process characterized by an inflammatory infiltrate of the myocardium with necrosis and/or degeneration of adjacent myocytes not typical of the ischemic damage associated with coronary artery disease (Aretz, 1987). Although inflammation can also occur as a result of ischemic injury, in myocarditis the inflammatory infiltrate plays a primary role in causing the myocardial damage.

The true incidence of myocarditis in the human population is unknown, but up to 10% of routine post-mortem examinations show histological evidence of myocardial inflammation (Gore and Saphir, 1947; Gravanis and Sternby, 1991). Because myocarditis is often difficult to diagnose with standard cardiologic tests, a definitive diagnosis depends on an endomyocardial biopsy, a relatively insensitive procedure due to the focal nature of the inflammation. Histologically defined disease has been confirmed in only approximately 30% of the patients with clinically suspected myocarditis, and in 30–60% of patients with DC (Marboe and Fenoglio, 1988; Peters and Poole-Wilson, 1991). The wide range in the rate of detection of myocarditis in biopsy specimens probably reflects local differences in diagnostic criteria and patient selection as well as the insensitivity of biopsy in general.

To further complicate diagnosis, myocarditis can be induced from many different agents including infections, immune-mediated reactions, or drugs (Table 1.1). Viral infections, such as Coxsackievirus B3 (CVB3) and cytomegalovirus (CMV), are widespread in the population, and most individuals in Western populations will be infected with one or both of these two viruses at some point, although acute viral myocarditis may occur frequently without clinical detection (Forbes, 1989; Grist and Reid, 1993). Advances in molecular techniques, such as genomic hybridization and the polymerase chain reaction (PCR), have confirmed the presence of infectious agents like CVB3 in the hearts of some myocarditis and DC patients, but the high prevalence of these infections in the population makes it difficult to relate infection with disease. Because these viruses are so common, diagnostic tests based on detection of viral antibody tend to be overly sensitive and the viral infection has usually cleared from the blood stream by the time heart disease occurs. Hence, a better understanding of the pathogenesis of disease is needed in order to find measures that both confirm diagnosis and determine whether the disease is at an early viral or later immune-mediated stage. When viruses directly damage myocytes or initiate immune-mediated damage is often unclear (Huber, 1997; Fairweather et al., 2001).

A number of infectious agents other than viruses are associated with myocarditis. Parasites such as Trypanosoma cruzi (the causative agent of Chagas disease) are the primary cause of myocarditis in Latin American populations where parasites are estimated to infect 16 to 18 million people (Table 1.1) (Cunha-Neto et al., 1996). Chagas disease can afflict nearly 50% of endemic populations with 80% of infected individuals developing myocarditis (Schoen, 1999). Likewise, bacterial infection with Streptococcus pyogenes may result in rheumatic heart disease, which remains a major cause of heart disease in many developing countries. Myocarditis has also been associated with systemic autoimmune diseases such as systemic lupus erythematosus and polymyositis.

Table 1.1

Major Causes of Clinical Myocarditis

Infections

Viruses (e.g., Coxsackievirus, CMV, influenza)

Bacteria (e.g., streptococci, Borrelia burgdorferi (Lyme disease), chlamydia)

Protozoa (e.g., Trypanosoma cruzi (Chagas disease))

Immune-mediated reactions

Post-viral

Post-streptococcal (rheumatic fever)

Systemic lupus erythematosus

Drug hypersensitivity (e.g., sulfonamides)

Transplant rejection

Chemical

Drugs (e.g., adriamycin, cocaine, lead)

Physical

Radiation

Hyperpyrexia

Exercise stress

Unknown

Sarcoidosis

Modified from Huber, S.A., 1997. Autoimmunity in myocarditis: relevance of animal models. Clin. Immunol. Immunopathol. 83, 93 and Schoen, F.J., 1999. The heart. Cotran, R.S., Kumar, V., Collins, T. (Eds.), Robbins Pathologic Basis of Disease. W.B. Saunders Co., Philadelphia, pp. 544.

2. Autoimmunity in Myocarditis

Soon after autoimmune diseases were first recognized more than a century ago, researchers began to associate them with infectious organisms. The basic task of the immune system is to recognize the myriad of foreign molecules that enter the body from the environment and to avoid harming self (Rose, 2002). Despite such protective mechanisms, autoimmune diseases are common in industrialized societies. Although autoimmune diseases present differently in different organs, they share many common mechanisms.

In order to better understand the relationship between infection and autoimmune disease, we established a mouse model of myocarditis induced by CVB3 (Fairweather et al., 2001). Coxsackievirus is believed to account for the majority of cases of myocarditis in North America and Europe (Fujioka et al., 1996; Friman and Fohlman, 1997), and the same virus is capable of inducing myocarditis in humans and mice. Following CVB3 infection, BALB/c mice develop an acute, focal inflammatory myocarditis with a mixed cellular infiltrate peaking around day 12 after infection (Fig. 1.1). Infectious virus can be detected in the heart during this time, but viral levels do not correlate with the severity of inflammation (Fairweather et al., 2001, 2003). Inflammation subsides by day 21 after infection, when heart sections look relatively normal under the microscope. A similar course also occurs following murine CMV (MCMV) infection of BALB/c mice (Fairweather et al., 2001). We surmise that a parallel sequence of events occurs in humans infected with diverse types of viruses such as CVB3 (a small, nonenveloped RNA virus) or CMV (a large, enveloped DNA virus). That is, individuals typically develop acute but self-limiting viral myocarditis that heals without residual lesions. In some individuals, as in susceptible mouse strains, the disease develops a chronic phase associated with inflammation and fibrosis accompanied by an autoimmune response to cardiac myosin and other cardiac antigens. The pathogenic process sometimes progresses to DC.

Figure 1.1  Progression to autoimmune myocarditis following Coxsackievirus B3 (CVB3) infection of BALB/c mice. Infection of BALB/c mice with CVB3 results in the development of acute, viral myocarditis. During this time, infectious virus can be detected in the heart, but does not correlate with the level of inflammation. The acute inflammatory infiltrate in CVB3 infection is comprised predominantly of macrophages, CD4 + T cells, CD8 + T cells, and B cells. The inflammation subsides by day 21 after infection. In BALB/c mice, the chronic, autoimmune stage of the disease emerges around day 28 after infection. Acute myocarditis is characterized by a mixed cellular infiltrate but very little necrosis or fibrosis, in contrast to the autoimmune chronic phase where the lymphocytic infiltrate is associated with large regions of fibrosis and necrosis that may be followed by the development of dilated cardiomyopathy (DC).

We propose that certain cytokines released in response to viral infection are key in driving the progression to chronic, autoimmune heart disease in mice. We have studied the influence of the immune response to the virus on the subsequent development of myocarditis using mice deficient in immune cells or cytokines due to antibody treatment or genetic manipulation. This chapter will focus on the role of these cells and cytokines in the pathogenesis of myocarditis in mice.

3. Pathogenesis: The Role of Cells and Cytokines

Although a number of animal species (such as primate, pig, dog, rabbit, guinea pig, and rat) have been used in myocarditis research, most animal investigations utilize mice (Huber, 1997). A number of experimental mouse models of myocarditis and DC have been developed, which closely reflect the course of human disease. These include immunization of animals with antigens, such as cardiac myosin, or the use of infectious agents such as viruses. The viruses most often studied in animal models include reovirus, encephalomyocarditis virus, MCMV, and CVB3.

Animal models have provided valuable information on factors important for susceptibility to viral infection, such as age, sex, nutritional status, pregnancy, and genetic background (Khatib et al., 1980; Huber et al., 1981; Wolfgram et al., 1986; Fairweather et al., 2001). Infants are more susceptible to Coxsackievirus infections than are young children or adults (Kaplan, 1988), and similarly, susceptibility in mice decreases with increasing age (Khatib et al., 1980). Furthermore, individuals in the human population respond differently to the same infectious agent, with similar observations reported with different mouse strains. Studies to determine the genetic predisposition for myocarditis involved infecting many types of inbred mouse strains with CVB3 (Wolfgram et al., 1986). Susceptibility to autoimmune myocarditis, whether inoculating with CVB3, MCMV, or cardiac myosin plus adjuvant, is under strict genetic control (Rose et al., 1988; Lawson et al., 1990; Fairweather et al., 2001; Rose and Afanasyeva, 2003). For example, A/J mice are highly susceptible, BALB/c mice are intermediate, and C57BL/6 mice are resistant to the development of the chronic, autoimmune phase of myocarditis (Fig. 1.1). Surprisingly, this susceptibility is due primarily to genes that are not part of the major histocompatibility complex (MHC) (Rose and Afanasyeva, 2003).

Key in our understanding of the control of susceptibility to autoimmune disease was the finding that inoculation with bacterial lipopolysaccharide (LPS), interleukin (IL)-1β, or tumor necrosis factor (TNF)-α after viral infection resulted in the development of the chronic, autoimmune phase of disease in resistant strains of mice (Lane et al., 1991, 1992; Lenzo et al., 2002). Moreover, when genetically susceptible A/J mice are treated with agents that block IL-1 or TNF, they fail to develop myocarditis induced by cardiac myosin (Neumann et al., 1993). From this series of experiments, we conclude that inflammatory mediators are critical for the development of a pathogenic autoimmune response following viral infection. The production of key cytokines following infection may vary depending on the virus, the mouse strain, the conditions surrounding the infectious process, or the interplay of these and other genetic and environmental factors.

3.1. Viral Mouse Model

Infection of BALB/c mice with CVB3 results in the development of acute myocarditis from day 7–14 after infection (Fig. 1.1). During this time, infectious virus can be detected in the heart, but does not correlate with the level of inflammation (Fairweather et al., 2003). The inflammatory infiltrate in CVB3 infection is comprised predominantly of macrophages, natural killer (NK) cells, CD8+ T cells, and CD4+ T cells, B cells and neutrophils (Godeny and Gauntt, 1986, 1987a,b; Henke et al., 1995; Fairweather et al., 2001). The inflammation in the heart subsides by day 21 after infection, when heart sections look relatively normal under the microscope. In BALB/c mice, the chronic, autoimmune stage of the disease emerges around day 28 after infection and can be detected at least until day 56 (Fairweather et al., 2001). Acute myocarditis following viral infection is characterized by a focal, mixed cellular infiltrate but very little necrosis or fibrosis, in contrast to the autoimmune chronic phase where a diffuse lymphocytic infiltrate is associated with large regions of fibrosis and necrosis that may be followed by the development of DC (Fig. 1.1).

It is important to note that many of the studies of virally induced myocarditis used high doses of virus that resulted in death during the acute phase of myocarditis (Huber, 1997; Horwitz et al., 2000; Fong, 2003). In these models, necrosis of myocytes and fibrosis can be observed during acute myocarditis with few animals surviving to the chronic phase. In contrast, a low dose of virus results in virtually no deaths, allowing 100% of mice to survive to develop chronic myocarditis and DC (Fairweather et al., 2001). Since young adults rarely die from acute Coxsackievirus infections (Schoen, 1999), we feel that the low-dose model more closely resembles the disease as it occurs in human populations. Interestingly, inoculation of higher doses of CVB3 actually results in lower levels of inflammation in the heart than inoculation of low doses (D. Fairweather, unpublished observations).

A study investigating the global expression profile of proinflammatory genes induced by acute and persistent CVB3 infection in human fibroblast cell cultures found the rapid induction of a typical spectrum of various inflammation-related genes including IL-1β, IL-6, IL-8, and a number of metalloproteases (MMP-1, MMP-3, and MMP-15), thus suggesting that IL-1 plays an essential autocrine role. Neutralization experiments confirmed that IL-1α and IL-1β were key factors for the induction of inflammation-related genes during CVB3 infection (Rehren et al., 2013).

Baldeviano et al. showed that the immunization of mice with myocarditogenic peptide in complete Freund adjuvant induced the infiltration of IL-17A–producing Th17 cells into the inflamed heart. However, the incidence and severity of myocarditis was similar in the IL-17A–deficient and wild-type mice (Baldeviano et al., 2010).

Treatment of BALB/c mice with anti-IL-17A monoclonal antibody administered after the onset of myocarditis abrogates myocarditis-induced cardiac fibrosis and preserves ventricular function (Baldeviano et al., 2010).

Further, IL-17A deficiency does not improve the myocarditis of interferon (IFN)-gamma–deficient mice, thus showing that IL-17A plays a minimal role during acute myocarditis. On the other hand, IL-17A–deficient mice are associated with reduced interstitial myocardial fibrosis and the absence of the development of post-myocarditis remodeling and progression to dilated cardiomyopathy (Baldeviano et al., 2010).

The use of a recent experimental autoimmune myocarditis (EAM) mouse model has shown that IL-17 promotes B cell autophagy and facilitates myocarditis severity (Yuan et al., 2014).

Savvatis et al. have recently investigated whether treatment with anti-IL-6 receptor antibody improves cardiac dysfunction and left ventricular (LV) remodeling in experimental CVB3-induced myocarditis. IL-6 receptor blockade shifted the immune response in a Th1 direction and significantly reduced viral load (Savvatis et al., 2014).

Recent evidence has shown that IL-17 contributes to cardiac fibrosis following experimental autoimmune myocarditis by means of a PKCβ/Erk1/2/NF-κB–dependent signaling pathway (Liu et al., 2012).

The increased frequency of IL-22–producing Th22 cells may play an important role in the pathogenesis of acute CVB3-induced mouse viral myocarditis, and IL-22 may act as a myocardium-protective cytokine via the IL-22-IL-22R pathway (Kong et al., 2012).

IL-35 is a member of the IL-12 cytokine family that plays a suppressive and antiinflammatory role in autoimmunity and the immune response to infectious agents (Hu et al., 2014). It also protects the myocardium from the pathogenesis of CVB3-induced viral myocarditis, possibly as a result of reduced Th17 production (Hu et al., 2014).

It has been shown that the autoreactive T-cell repertoire derived from mice infected with CVB3 includes frequent IL-17-producing cells capable of inducing myocarditis in naïve recipients. This demonstrates that CVB3 can primarily infect the heart, lead to autoreactive T cells, and contribute to cardiac pathology (Gangaplara et al., 2012).

3.2. Cardiac Myosin Mouse Model

Cardiac myosin is the major target of the autoimmune response in many cases of myocarditis in humans and mice (Neu et al., 1987; Caforio et al., 1996; Wang et al., 1999; Lauer et al., 2000). Evidence that persistent viral infection is not required for the development of myocarditis comes from the demonstration that inoculation of BALB/c mice with cardiac myosin, emulsified in complete Freund adjuvant, induces an experimental autoimmune myocarditis (EAM) that closely resembles the myocarditis associated with CVB3 infection (Fig. 1.1) (Neu et al., 1987; Lawson et al., 1992; Rose, 1996). Twenty-one days after immunization, the disease is characterized by a predominantly mononuclear infiltration of the myocardium and some cardiomyocyte death and replacement fibrosis (Fig. 1.1). The myocardial infiltrate contains many macrophages, CD4+ T cell and some CD8+ T cells, and B220+ B cells (Pummerer et al., 1991; Wang et al., 1999). Among the infiltrating cells are eosinophils and occasional giant cells, both of which are more prominent in severe myocarditis as often occurs in highly susceptible A/J mice (Afanasyeva et al., 2001a). At later time points, inflammation recedes and myocardial fibrosis becomes the hallmark of disease, similar to the late chronic phase of myocarditis after viral infection (Fig. 1.1). Extensive myocardial damage eventually leads to the development of DC and congestive heart failure (Afanasyeva and Rose, 2002).

After the injection of cardiac myosin peptide emulsified in complete Freund adjuvant, IL-6 plays a key role in EAM pathogenesis (Eriksson et al., 2003).

IL-6–deficient mice show a reduction in innate and adaptive immune responses including the expression of adhesion molecules, inflammatory responses, and autoantibody levels, and the expansion of autoimmune CD4+ T cells, possibly due to the upregulation of complement C3 (Eriksson et al., 2003).

There are increasing data concerning the role of antagonists of P2X7 receptors (which are involved in the pathophysiology of cardiovascular inflammation) in suppressing the development of EAM (Zempo et al., 2015). In a recent study in which mice with experimental autoimmune myocarditis were treated with the P2X7 receptor antagonist A740003 (n  =  10) or not (n  =  11), the hearts harvested on day 21 showed that the antagonist improved myocardial contraction by suppressing the infiltration of CD4+ T cells and macrophages. Further, the mRNA expression of IL-1 β, the P2X7 receptor, and NADPH oxidase 2/4 was lower in the heart of the P2X7 receptor antagonist-treated group (Zempo et al., 2015).

3.3. Role of Cells

Myocarditis may be the result of myocardial infection (i.e., Trypanosoma cruzii or Coxsackievirus) or sterile inflammation induced by various causes (cardiac surgery, allergic reactions, excessive stress) in a genetically predisposed subject. In both situations, microbial or endogenous products may trigger the immune response.

Both cellular and humoral autoimmunity are involved in the pathogenesis of CVB3-induced myocarditis in susceptible mice, but distinct pathogenic mechanisms may function in different strains of mice. For example, CBV3 infection in DBA/2 mice has an exclusively humoral pathogenesis, whereas BALB/c mice develop primarily cell-mediated disease, and the pathogenesis of disease in A/J mice involves both autoimmune T cells and autoantibodies (Huber and Lodge, 1986; Lodge et al., 1987).

Various cell populations belonging to the immune system or of cardiac origin are presumably involved in the pathogenesis of myocardial inflammation. Both may have proinflammatory or antiinflammatory properties, and cells belonging to the immune system can give rise to innate and adaptive responses.

The innate immune response to pathogens has recently aroused considerable interest. It used to be thought that innate immunity only provides rapid (but incomplete) antimicrobial host defense before the development of the slower, more definite acquired immune response (Fearon and Lockley, 1996; Parish and O'Neill, 1997; Hoffmann et al., 1999), but recent research indicates that innate immunity critically affects the subsequent development of the adaptive immune response and autoimmunity (Carroll and Prodeus, 1998; Seder and Gazzinelli, 1999; Kadowski et al., 2000; Kaya et al., 2001). How innate immunity controls the initiation of an adaptive response and the development of autoimmune disease is not clear, but is likely to involve the innate immune cell release of proinflammatory cytokines.

Innate responses involve neutrophils, macrophages, monocytes, and innate lymphoid cells.

Neutrophils are the first cells recruited in the case of cardiac injury. During myocardiocyte necrosis, mitochondrial DNA and formylated peptides, which have a similar molecular structure to that of bacterial products, may attract and activate neutrophils by interacting with toll-like receptors (TLRs) or formyl-peptide receptor-1, and the release of cytokines such as IL-1, IL-6, and TNFα further promotes the recruitment of neutrophils at the site of injury. IL-6 may be released by injured cardiomyocytes, monocytes, macrophages and, in an autocrine manner, by neutrophils themselves. IL-17, another cytokine that strongly recruits and activates neutrophils, is produced by mononuclear cells and its production decreases following neutrophil apoptosis, thus establishing negative feedback. Neutrophils sustain inflammation by secreting proteases and reactive oxygen species.

Monocytes and resident macrophages may also contribute to inflammation and tissue repair. Circulating monocytes are induced to adhere to cardiac vessels in order to reach the damaged tissues. Different pools of circulating monocytes may account for different pathogenic roles mouse models: e.g., Ly6cHi monocytes are recruited in the case of ischemic or hypertensive cardiac damage, whereas Ly6cLow monocytes are not (Epelman et al., 2015).

Resident macrophages can be divided into three subsets on the basis of the expression of major histocompatibility class II and C–C chemokine receptor 2 markers (CCR2). The pool of CCR2+ macrophages, which are mainly derived from circulating monocytes, expands after an inflammatory stimulus, and may activate the NLPR3 inflammasome pathway in response to ischemic, hypertrophic, or hypertensive diseases, thus generating large amounts of IL-1. Conversely, CCR2-resident macrophages are indispensable for myocardial tissue remodeling, scar healing, and repair. Macrophages are also involved in the phagocytosis of apoptotic cells, including neutrophils, and impaired clearance (possibly due to local inflammation and an imbalance of regulatory and proinflammatory cytokines) may amplify the inflammatory burden.

Cells belonging to the innate immune response, may recognize microbial and endogenous peptides [pathogen-associated molecular patterns and damage-associated molecular patterns (DAMPs)] via the TLR pathway, and generate a cascade of intracellular signals culminating in the nuclear translocation of NFkB and the final transcription of various genes coding for the cytokines and other molecules involved in the inflammatory response. MyD88 or IL-1 receptor–associated kinase 4 (IRAK4) knock-out mice infected with CVB3 show a more favorable disease course related to the reduced nuclear translocation of NFkB and the higher production of protective type I interferons.

NK lymphocytes anticipate the adaptive response by secreting large amounts of IFNγ after encountering the antigen. A recent study of murine EAM has shown that NK lymphocytes may prevent the infiltration of the eosinophils finally responsible for myocardium fibrosis directly (by inducing apoptosis) or indirectly by inhibiting the release of chemokines (Ong et al., 2015).

NK cells are an important first line of defense against viral infections as they efficiently limit the replication of CVB3 and MCMV (Godeny and Gauntt, 1987a; Bancroft, 1993; Tay et al., 1998). When antigen-presenting cells detect a viral infection of host tissue, they release cytokines and chemokines that attract NK cells to the site of infection. The ability of NK cells to produce IFNγ rapidly after infiltrating infected tissues and before the clonal expansion of T cells is critical for an effective innate immune response (Fairweather and Rose, 2002). Depleting NK cells by means of anti-asialo GM1 (a pan-NK marker) increases myocarditis in outbred CD-1 mice with CVB3 infection (Godeny and Gauntt, 1986), thus suggesting that NK cells primarily protect against myocarditis by inhibiting viral replication. In order to examine the role of NK cells in the development of acute MCMV-induced myocarditis, NK1.1+ cells have been depleted from normal C57BL/6 or BALB.B6-Cmv1r mice using antibodies against NK1.1 (Table 1.2) (Fairweather et al., 2001). BALB.B6-Cmv1r is a congenic mouse strain that carries the NK cell gene complex found in B10 mice (i.e., NK1.1) on a BALB/c genetic background (Scalzo et al., 1995). As BALB/c mice do not have NK1.1 cells, they primarily clear MCMV infection by means of the cytolytic activity of CD8+ T cells (Lathbury et al., 1996). Depleting NK1.1+ cells from C57BL/6 or BALB.B6-Cmv1r mice significantly increases myocarditis to levels found in BALB/c control mice (Table 1.2). The role of NK cells in NK1.1− BALB/c mice is not yet clear, but these findings indicate that the protection mediated by NK cells during acute myocarditis is more important in reducing myocarditis than other traits in the BALB/c genetic background as the only difference between congenic and regular BALB/c mice is the NK-cell gene complex.

Table 1.2

Role of Immune Cells in Murine Cytomegalovirus-Induced Myocarditis

a BALB/c (do not have NK1.1+ cells), BALB.B6-rCmv1 (BALB.B6 congenic) (have NK1.1+ cells on a BALB/c genetic background), and C57BL/6 mice (have NK1.1+ cells on a C57BL/6 genetic background) were infected with MCMV intraperitoneally.

b Mice were also treated with antibodies that deplete NK1.1+ cells, CD4+ T cells, CD8+ T cells, both CD4+ and CD8+ T cells, or saline control. Successful cell depletions were confirmed by FACS analysis (data not shown).

Modified from Fairweather, D., Kaya, Z., Shellam G.R., 2001. From infection to autoimmunity. J. Autoimmun. 16, 175.

Cells belonging to the adaptive immune system include dendritic cells and T and B lymphocytes. Dendritic cells (DCs) can recognize antigenic peptides and present them to T lymphocytes, thus further guiding their differentiation. In response to different TLR stimulation, these cells may secrete IL-23, IL-12, or IL-4, thus promoting the differentiation of autoreactive T helper cells. On the contrary, following other specific molecular pathways such as the production of nitric oxide, DCs may counteract the expansion of T effector cells and favor the expansion of the T regulatory pool (Kania et al., 2013). The survival and activation of DCs seem to be related to a paracrine loop that intertwines these cells with cardiac fibroblasts.

The involvement of autoimmune T cells in the pathogenesis of CVB3-induced myocarditis was first inferred from the observation that T-cell depleted mice have less severe disease than normal mice (Woodruff and Woodruff, 1974). It has been shown that T cells play a decisive role in disease pathogenesis in models of both CVB3- and MCMV-induced myocarditis (Lawson et al., 1989; Schwimmbeck et al., 1997). Athymic nude mice also develop less severe disease after CBV3 or MCMV infection (Hashimoto and Komatsu, 1978; Lawson et al., 1989). Furthermore, myocarditis can be transferred by inoculating autoimmune CD4+ T cells from virally infected mice to uninfected recipients (Guthrie et al., 1984; Huber, 1997). The infection of mice depleted of T cell subsets or genetically altered to the same effect leads to less severe myocarditis (Henke et al., 1995; Schwimmbeck et al., 1997; Fairweather et al., 2001). Table 1.2 shows the important role T cells (particularly CD8+ T cells) play in the development of acute MCMV-induced myocarditis in BALB/c mice (Fairweather et al., 2001). Although depleting CD4+ T cells from MCMV-infected BALB/c mice reduces myocardial inflammation, the reduction is far more dramatic if CD8+ T cells are removed, alone or together with CD4+ T cells. Furthermore, acute myocarditis is more severe in CD4 C57BL/6 knockout (KO) mice (CD4+ T cells are absent due to gene deletion) following CVB3 infection (Henke et al., 1995). These studies confirm that the development of myocarditis, although requiring a virus to initiate the process, also needs components of adaptive immunity for disease progression.

Autoreactive T cells and autoantibodies are also present in myosin-induced EAM (Neu and Ploier, 1991; Pummerer et al., 1995). T cells are necessary for the development of disease in this model, with myosin-stimulated T cells capable of transferring myocarditis into immunodeficient severe combined immunodeficient mice (Smith and Allen, 1991, 1993; Pummerer et al., 1995). Depleting CD4+ or CD8+ T cells in myosin-immunized susceptible mice diminishes myocarditis, thus suggesting that both cell types are important in the pathogenesis of EAM, as well as virally induced models (Pummerer et al., 1991; Smith and Allen, 1991, 1993; Penninger et al., 1993). However, CD4 KO mice have reduced inflammation, but myocarditis is exacerbated in immunized CD8 KO mice (Penninger et al., 1993; Pummerer et al., 1995), which indicates that CD8+ T cells sometimes suppress the disease in this model. CD4+ T cells are involved in the pathogenesis of EAM as they recognize the antigens presented by MHC class II (Smith and Allen, 1992a; Donermeyer et al., 1995), which may be important regulatory molecules for the induction of autoimmunity (Todd et al., 1988; Nepom, 1993). An understanding of the cell mechanisms driving the autoimmune response in EAM may help to distinguish the role of the cellular response to viral infection from that directed against cardiac myosin.

CD4+ T helper lymphocytes may differentiate into various subsets depending on the cytokine milieu. Th1 lymphocytes are the main producers of IFNγ and IL-2. IFNγ activates macrophages by increasing the expression of MCP-1 (the data concerning fibroblast activation are uncertain), whereas Th2 cells mainly producing IL-4, IL-5, and IL-13 are responsible for the phenotypic transition of fibroblasts into myofibroblasts and the inhibition of extracellular matrix degradation.

By secreting IL-17, Th17 lymphocytes induce the downstream production of IL-1, IL-6, TNFα, chemokines, and granulocyte colony-stimulating factors, which have multiple effects on the inflammatory cascade. Th17 lymphocytes induce the production of autoantibodies and may simultaneously favor and inhibit heart fibrosis (Machino-Ohtsuka et al., 2014), whereas recent studies have highlighted the protective role of Th22 lymphocytes in both infective and autoimmune myocarditis (Amoah et al., 2015). Similarly, T regulatory cells have antiinflammatory and antifibrotic effects by secreting IL-10. It has been reported that a genetically determined imbalance between Th17/Th1 and T regulatory lymphocytes is related to a higher risk of developing autoimmune myocarditis in mice models (Chen et al., 2012).

Cardiac remodeling is the final step of the inflammatory process occurring during myocarditis and may lead to dilated cardiomyopathy. This is due to a complex interplay between innate and adaptive immune cells, cardiac cells, and fibroblasts. Cardiac fibroblasts are responsible for the homeostasis of the extracellular matrix (ECM) and also preside over mechanical and electrical functioning. They represent 60–70% of all cardiac cells and may arise from a local embryonic pool, or endothelial, or bone marrow cells recruited under inflammatory conditions. Cardiac fibroblasts may change from a contractile α-smooth muscle actin to an active-secreting phenotype. In addition to producing collagen and other components of the ECM, they may also synthesize and respond to many cytokines, hormones, and growth factors. TLRs are found on cardiac fibroblasts and may induce the deposition of collagen types I and III, thus leading to cardiac fibrosis. The production of the ECM is controlled by macrophages through the release of metalloproteases and tissue growth factor-β (TGFβ), which respectively have antifibrotic and profibrotic effects.

In conclusion, the cell network of myocarditis embraces a wide spectrum of effectors, ranging from professional cells belonging to the immune system to resident stromal cells. The cytokine milieu les at the basis of cell differentiation and activation and may favor or antagonize the inflammatory cascade.

3.4. Role of Cytokines

Many of the mediators associated with the innate immune response, particularly cytokines, can act in a long-range endocrine manner so that antigen-presenting cells far removed from the site of infection are activated to present either viral or autoantigens to T and B cells (Parish and O'Neill, 1997; Carnaud et al., 1999; Kadowski et al., 2000). Moreover, recent evidence suggests that a bidirectional relationship exists between innate and adaptive immunity (Rose, 2011).

IFN-α production following viral infection stimulates an effective NK cell response. The type 1 IFNs belong to a multigene family that include multiple IFN-α subtypes and IFN-β (Bellardelli, 1995). IFNs also provide an important link between the innate and adaptive immune responses (Kadowski et al., 2000). Previous studies have shown that administration of IFN-α subtypes or IFN-β to MCMV-infected BALB/c mice not only reduces viral replication, but also decreases acute and chronic myocarditis (Table 1.3) (Lawson et al., 1997; Yeow et al., 1998; Fairweather et al., 2001). These results emphasize the role of innate cytokines in modulating the adaptive immune response and autoimmune disease.

As pointed out previously, cytokines can determine whether mice develop autoimmune myocarditis. For example, administration of IL-1 or IL-2 augments disease in CVB3-infected susceptible mice (Table 1.3) (Huber et al., 1994), while blocking these receptors inhibits the development of myocarditis (Neumann et al., 1993). On the other hand, C57BL/6 mice, which are resistant to the development of chronic myocarditis following CVB3 or MCMV infection, can be induced to develop chronic myocarditis by administration of LPS (a generator of several proinflammatory cytokines), IL-1β, or TNF-α with the virus (Table 1.3) (Lane et al., 1991, 1992; Lenzo et al., 2001). Cytokines may play a number of different roles. They may provide second signals after viral infection that stimulates an effective protective immune response or a deleterious response in individuals susceptible to autoimmune disease (Fairweather et al., 2001). Thus, certain cytokines can influence whether chronic autoimmune disease develops in response to viral infection, bridging the gap between the innate and adaptive immune response.

LPS and TNF-α are also important in the development of cardiac myosin-induced myocarditis. Neutralization of TNF-α effectively inhibits the initiation of EAM, although neutralization is not beneficial in suppressing ongoing disease (Table 1.4) (Smith and Allen, 1992b). TNF-α is believed to be necessary for upregulating MHC class II binding of self-reactive peptides on antigen-presenting cells in EAM, since upregulation of MHC and accessory molecules fails to occur in TNF-deficient mice (Smith and Allen, 1992a). Furthermore, myocarditis can be transferred by injection of cardiac myosin-specific T cells into mice pretreated with LPS or TNF-α (Penninger et al., 1997). Thus, the primary role of virus or adjuvant, in the EAM model, may be to provide an optimal cytokine environment (i.e., increased IL-1β and TNF-α) in the context of self-antigen thereby allowing an autoimmune response to occur.

According to the current dogma, inflammatory autoimmune diseases are primarily attributable to Th1 responses, of which IFN-γ is the prototypic cytokine, while Th2 responses, where IL-4 predominates, should reduce autoimmunity (Cunningham, 2001). Th1-mediated immune responses have been implicated in the pathogenesis of a number of autoimmune diseases including inflammatory bowel disease, type I diabetes, multiple sclerosis, and rheumatoid arthritis (O'Garra, 1998). IFN-γ stimulates Th1-cell development, activates macrophages, induces MHC class I and II expression, promotes delayed-type hypersensitivity reactions, induces certain immunoglobulin class switching, recruits Th1 cells to the site of inflammation, and is important for clearing intracellular bacteria, parasites, and viral infections (Boehm et al., 1997). IL-4, on the other hand, stimulates Th2-cell development, activates B cells, induces MHC class II expression on B cells, promotes allergic reactions, induces immunoglobulin class switching to immunoglobulin (Ig) G1 and IgE, recruits eosinophils and Th2 cells to the site of inflammation, and is important for clearing parasites (Nelms et al., 1999). Thus, determining whether a predominantly Th1 or Th2 immune response occurs to virus or cardiac myosin immunization may promote understanding the pathogenesis of autoimmune heart disease.

Table 1.3

Role of Cytokines and Cytokine Signaling in Virus-Induced Myocarditis

BL/6, C57BL/6; CB3, Coxsackievirus B3; DC, dilated cardiomyopathy; IFN-α/γ, interferon-α/γ; IL, interleukin; KO, knockout; LPS, lipopolysaccharide; p402, p40 homodimerR, receptor; STAT, signal transducer and activator of transcription; TLR4, toll-like receptor 4; TNF, tumor necrosis factor.

a BALB/c mice are used unless otherwise stated.

Table 1.4

Role of Cytokines and Cytokine Signaling in Cardiac Myosin-Induced Myocarditis

Ab, Antibody; EAM, experimental autoimmune myocarditis; IFN-α/γ, interferon-α/γ, BL/6, C57BL/6; IL, interleukin; KO, knockout; p402, p40 homodimer; R, receptor; STAT, signal transducer and activator of transcription; TNF, tumor necrosis factor.

a Using A/J or BALB/c mouse strains.

It has been demonstrated that CD4(+) Th17 cells and Th17-produced cytokines play a critical role in inflammation-induced cardiac remodeling and the progression to dilated cardiomyopathy. It has been hypothesized that blocking IL-17A may be therapeutic option for inflammatory cardiomyopathy (Baldeviano et al., 2010; Myers et al., 2016) as it plays a key role in the myocardial upregulation of IL-6, TNFα, and IL-1β, and the recruitment of CD11b(+) monocytes and Gr1(+) granulocytes in the heart (Baldeviano et al., 2010). Furthermore, it has been found that IL-17A can induce cardiomyocyte apoptosis through the p38 mitogen-activated protein kinase (MAPK)-p53-Bax signaling pathway, and promotes both early- and late-phase post-myocardial infarction (MI) ventricular remodeling (Zhou et al., 2014).

It has also been shown that a Th17-cell immunophenotype is linked with the effects of cardiac myosin, which acts as an autoantigen arising from damaged myocardiocytes on CD14(+) monocytes and TLR2 and heart failure.

High levels of IL-17–producing T cells and IL-17–promoting cytokines cells are associated with persistent heart failure, and it has been shown that the myocarditis/dilated cardiomyopathy phenotype contains low percentages of FOXP3(+) Tregs that contribute to disease severity. TLR2 peptide ligands from human cardiac myosin can stimulate exaggerated Th17-related cytokines such as TGFβ, IL-6, and IL-23 from myocarditic CD14(+) monocytes in vitro (Myers et al., 2016).

It has been reported that the myeloid differentiation factor (MyD)88/IL-1 axis in the bone marrow compartment plays a critical role in post-inflammatory cardiac fibrosis and heart failure (Blyszczuk et al., 2009).

IL-12 is produced by phagocytic and antigen-presenting cells. Produced during the early phase of an infection, IL-12 promotes the differentiation of T cells to a Th1 phenotype with IFN-γ production, which in turn supports cell-mediated immunity, cytotoxic T-cell generation, activation of phagocytic cells, and eventual eradication of intracellular pathogens (Ma and Trinchieri, 2001). IL-12 is a heterodimer composed of IL-12p35 and IL-12p40 subunits bound via disulfide bonds and secreted as a biologically active IL-12p70  molecule. IL-12 receptors (R) are primarily expressed on activated NK and T cells, and signaling requires coexpression of the IL-12Rβ1 and IL-12R β2 chains for the generation of high-affinity IL-12p70 binding and maximal IFN-γ production. In the mouse, IL-12R signaling activates the signal transducer and activator of transcription (STAT)1, STAT3, and STAT4, with STAT4 being responsible for most of the biological activities of IL-12 through the production of IFN-γ (O'Garra, 1998; Moser and Murphy, 2000). IL-12p40 is also produced as a monomer and homodimer (p402) in great excess over IL-12p70. The IL-12p40 homodimer